Accusations of euthanasia are common as patients, families and even other health professionals struggle to adjust to the new realities of end-of-life care.

Three decades after hospice emerged as the standard of care for terminally ill patients, the end-of-life treatments that palliative medicine physicians provide are frequently referred to as murder, euthanasia and killing.

More than half of hospice and palliative medicine physicians say patients, family members and even other health professionals have used those terms to describe care they recommended or implemented within the last five years, according to a nationwide survey of 663 palliative care doctors in the March Journal of Palliative Medicine.

Common palliative care treatments such as the use of opiates, sedatives and barbiturates to control pain and other symptoms are enough to draw accusations of murder and euthanasia, the study said. The troubling survey results come nearly six years after the American Board of Medical Specialties approved the hospice and palliative medicine subspecialty certification, and 30 years after the creation of the Medicare hospice benefit.

Nearly 1.6 million Americans received hospice care in 2010, up from about 25,000 in 1982, said the National Hospice and Palliative Care Organization. And palliative medicine has made its presence felt in hospitals, with 85% of 300-plus bed hospitals boasting palliative care teams, according to the New York City-based Center to Advance Palliative Care.

Yet the growing use of hospice and palliative care is creating more opportunities for misunderstandings, experts said. New developments in end-of-life care  aggressive pain and symptom management (even to the point of unconsciousness), along with a greater willingness to withdraw advanced, life-sustaining treatments such as mechanical ventilation, dialysis, and artificial hydration and nutrition  still strike many people as wrong.

The surveys findings highlight the gap between the well-established ethical and legal boundaries that demarcate acceptable end-of-life care and the understanding of patients, families and other members of the health care team, experts said.

Nearly 1.6 million Americans received hospice care in 2010, up from about 25,000 in 1982.

Its alarming, said H. Rex Greene, MD, a practicing oncologist and palliative medicine specialist in Lima, Ohio. To accuse legitimate palliative care physicians of euthanasia and murder is a horrible mischaracterization of whats done to relieve symptoms at the end of life.

Twenty-five of the physicians surveyed said they were formally investigated by their institutions, state medical boards or prosecutors, with about half of those cases related to the use of opiates to manage dying patients pain. Nearly a quarter of the investigations were related to the use of palliative and sedative medications when discontinuing mechanical ventilation. An additional 8% of the investigations were for palliative sedation  the practice of sedating to unconsciousness terminally ill patients who have severe, refractory pain.

All of these treatments  when conducted with the consent of patients or surrogate decision-makers and implemented with the intent of alleviating pain or other symptoms in terminally ill patients  are broadly accepted as ethically and legally appropriate, even if they have the secondary effect of speeding the dying process.

Physicians have an obligation to relieve pain and suffering and to promote the dignity and autonomy of dying patients in their care, says the American Medical Association Code of Medical Ethics. This includes providing effective palliative treatment even though it may foreseeably hasten death.

Hard-wired misperceptions

Although none of the physicians investigated was found at fault, most reported worry, anger, anxiety, isolation, depression and difficulty working as a result of the ordeal. Euthanasia accusations  whether voiced in the patients room or in the courtroom  could have a chilling effect on physicians treatment of dying patients symptoms, said John G. Carney, CEO of the Center for Practical Bioethics, a Kansas City, Mo., think tank that works to improve end-of-life care.

Im deeply concerned that if we dont pay attention to the message in this article, we are going to be dealing with this issue of physicians who are reluctant to do what they know to be right because they are afraid of what people will say or that someones going to investigate, said Carney, a former hospice executive director.

The distinction between aggressive pain control or the withdrawal of life-sustaining treatments and euthanasia is still lost on many patients and families, physicians said.

These misperceptions are really pretty hard-wired and difficult to eliminate, said David Casarett, MD, chief medical officer of the University of Pennsylvania Health Systems hospice program in the Philadelphia area. Believe me, if there were an easy way to communicate these issues, then we wouldnt have highly qualified physicians called before medical boards to explain their actions. To some degree, this is a cultural change. Were far ahead of where we used to be 20 years ago. On the other hand, we cant wait another 20 years for these things to go away.

Transformation in end-of-life care

Doctors who care care for dying patients should take into account the publics lagging understanding of end-of-life treatments, take time to explain their intricacies and make use of ethics consultation services, said Porter Storey, MD, executive vice president of the American Academy of Hospice and Palliative Medicine.

When I started training in this area 30 years ago, it was a rare thing to remove a feeding tube because nobody lived long enough to get that sick, said Dr. Storey, who practices outpatient palliative care in Boulder, Colo. Now many people are living until they are extremely debilitated on life support. And if you work in an ICU, you want to sit down and take time and talk to people, but when its happening every day, its hard to remember sometimes that the public didnt get informed that things have changed.

Yet confusion about end-of-life care is not limited to patients and families. A majority of the doctors surveyed said that other physicians or health professionals at times characterized their palliative care treatments as murder, euthanasia or killing.

As end-of-life care has become more specialized, the gap between what palliative care specialists see as appropriate care and other doctors perception of those treatments has grown, physicians said.

Those of us in palliative care and hospice dont think that much about putting a patient on a large dose of an opioid like morphine. We do it all the time, and we see patients do well, said Dr. Casarett, associate professor of medicine at the Perelman School of Medicine at the University of Pennsylvania.

Recently, a patient dying of cancer enrolled in Dr. Casaretts hospice program after deciding to stop chemotherapy treatment. The oncologist caring for the patient was upset and talked with Dr. Casarett, saying that the combination of stopping curative treatment and using high doses of opiates was wrong.

He said, We might as well just be walking away, and we might as well just shoot [the patient] now, Dr. Casarett recalled.

It still stings to hear that, he said. But Dr. Casarett takes solace in knowing that he is doing right by his patients. I tell other physicians that this is the standard of care, and that these sorts of medications and interventions are safe and effective.

ADDITIONAL INFORMATION:

Whos calling palliative care euthanasia

More than half of palliative care doctors have been told the care they recommended or provided is murder, euthanasia or killing. The frequency of such accusations varies by source and at times includes other doctors.

Hospice is not to be feared, and I regret the posters who paint these wonderful people in such a bad light. They are wrong, in my humble opinion.

Some hospices are very good. Some are indeed to be feared, like the one that killed Terri Schiavo.

The hospice we are working with just had a woman come to her in the past month who had been refused by two other hospices. She has esophageal cancer and has had a feeding tube for years without difficulties. She is starting to go downhill, not on death's door, but in need of hospice care. She cannot swallow on her own due to the prior treatment for the esophageal cancer.

She was told by TWO hospice providers that they would not take her unless she agreed to stop the feeding by feeding tube. She has months to live. Agreeing to their terms, which violate federal guidelines, would be a premature death sentence.

I agree entirely. I am a caregiver of 27 years to my wife. I have worked though not involved with patent care in nursing homes before. I was the caregiver to my terminal dad. Dad told me he wanted to go be with his Pappa. I knew what he meant. He had died in the mid 1940's when my dad was a teen.

I've see stuff in nursing homes I pray never happens to me or a loved one. I don't mean mistreatment. I mean people for which the medical knowledge of the early 1990's could not stop their pain without it becoming a lethal dose. I know because I heard their screams. These weren't the dementia patients these were terminal in pain and death could still be a month or two away.

My conscience in my caring for my dad is clear. People who think the magical answer is tubes etc need to understand THEY HURT and they feel pain much more intense. I've known patient after patient who ripped them out. The process some go through in their last conscious hours makes keeping anything on them or inside them as a catheters virtually impossible. They want everything off of them and out of them clothes, linen, tubes, you name it.

54
posted on 04/29/2012 8:45:27 PM PDT
by cva66snipe
(Two Choices left for U.S. One Nation Under GOD or One Nation Under Judgment? Which one say ye?)

And, I am so sorry for the loss of yours. Do not let the Hospice-trashers cause you and yours any second thoughts.

When my husband refused food and water, I was so blessed to have people around me to explain the why and the how of how death happens.

We must respect what their bodies are telling us, and not interfere with that wisdom, even if it makes us feel heroic, good about ourselves, or whatever.

If we love them, we respect them. We give them what they want, and if they do not want, we do not force ourselves upon them.

We hold their hands, we tell them how much they have mattered to all of us, and we tell them that we will never forget them.

We tell then that it is ok to go when they think they are ready, and that we will sit with them until that time comes. We tell them again and again, how much we appreciate their lives, what they have given to all of us, and how we will love them, warts and all, forever

My father discovered that he had developed pancreatic cancer too late for anything other than chemotherapy and radiation. Fortunately, he had access to incredible medical care from the best in the pancreatic cancer business.

For those who do not know, this type of cancer is painful and relief from that pain requires a significant amount of medication, including opiates. In addition, not only are there physical aspects to dying that are hard to anticipate and unique, there are also great mental challenges as you begin to face your end on Earth.

My father was a devout Catholic, outspoken anti-abortion, and gave money to a myriad of causes designed to help people in need. He also was very giving of his time, helping countless children mature and grow into responsible adults.

After fighting this horrible disease - nothing can prepare you to watch someone suffer in this manner - for 14 months, he could fight no more. In fact, there came a definitive point where he knew he would soon die. Everyone likes to think that their father is tough, and mine was provably so, but after making every sacrifice, allowing his body to be poked and prodded for more than a year, and trying every available remedy, he accepted that he was destined for Heaven.

We did speak with Hospice, and in fact signed him up for the program for him to die at home as peaceful as possible. However, that same evening he began to experience the greatest pain of his entire journey and instead of calling Hospice, my mother decided to take him to the hospital. That is where he was admitted to the palliative care floor at his hospital, and was where I learned a new phrase (palliative care) and what that entailed.

He had little time left to be conscious, in fact only 2.5 days in hindsight, so there was a flurry of activity to make final plans, say goodbye, and try to make him as comfortable as possible. His doctor, who was the most wonderful, caring, a compassionate person you could ask for, who had stuck with him throughout the journey, was there. He told her that he was ready to die, that he was done fighting, and that if they could give him a shot right there to take him out of his misery, he would take it. In absence of that option, he asked that he be kept free from pain.

From that point forward, it is hard to put into words what I witnessed. Along with my mother, we lived for almost 10 days in that little room (I left for roughly 6 hours in that time period, my Mom almost none) caring for him the best that we were able. I had never witnessed someone die in this manner, let alone my father, and there are sounds, sights, smells, and other things that were horrible to experience. He was essentially unconsciousness for 7 days, though there were a few brief moments where he “woke up” and tried to communicate with us. We had worked with the staff at the hospital to increase his morphine intake until he no longer exhibited outward signs of pain, and it certainly affected his ability to communicate and function.

Regarding hospice care and palliative care, at the time I did not give too much weight to the fact that they only kept him on a slow IV for hydration and no nutrients whatsoever. He asked to be kept pain-free and he acknowledged his fast-approaching death. The reason behind the extreme pain that led him to the hospital this final time was an intestinal blockage that prevented him from digesting food. Essentially, without external infusion of a source of nutrients, he was a goner no matter what at this point - the disease had reached its apogee.

Did the lack of nutrients hasten his death? Probably... Did the large amount of opiates hasten his death? I don’t know, but possibly... Did he want to die? Yes. Would he have accepted a quick death at the end without suffering? Yes, he specifically requested it from his doctor, but she refused.

In hindsight, I did feel that he was at least partially starved to death in the end, but I have to ask - why would we want to prolong his suffering? To what end? He wanted to go to God... He wanted the pain to end. He was tired of suffering and made his choices lucid and after much reflection. Had we given him nutrients, he could have possibly lived for a month or more while in extreme pain from the blockage. As it was, he made it almost 10 days and we were successful in keeping it mostly pain-free, but it wasn’t a 100% pain-free experience.

I miss my Father and it was hard to watch such a strong man get destroyed by such a ruthless disease, but the disease was destined to win over his physical body. This is without doubt or question - He was terminal. Upon reflection, I think that what the staff at the palliative care ward in the hospital accomplished was amazing. To a person, they were loving, kind, sympathetic, helpful, caring, and strong. They worked very hard to make sure that my father suffered as little as possible as he completed his journey here and began his next. Were I in his shoes, I don’t know what I would have done the same or different, but the terminal suffering would have heavily weighed in my decisions. He made his choice to move on and we accepted all of the assistance that we could to help him with his wish.

I don’t think that there ever will be a template that can be used to make these types of decisions, though our “leaders” are going to try. Ultimately, if it can be competently made by the patient, that is who’s wishes should be honored to the best of our ability.

That is exactly how we have done this. We just wish that my in-laws lived closer than 1100 miles so my wife could spend more time helping. We were there a few weeks ago repairing house projects and clearing the blackberries that have over taken the house. All is good for the time being.

Didn’t realize it at the time, but my father was killed by morphine. The whole family gathered around his bedside for a 24 hr vigil while he was dying. They kept him on morphine to “ease his pain.” He slept peacefully around the clock until he was gone. My older sister died recently. I visited her in the hospital just a couple days before she died. She didn’t feel well but was talking and joking with us. Was surprised to learn the next day they sent her home to die. I went to her home and the family was gathered around her bedside as she slept, on morphine to “ease her pain” right up to her last breath. My brother’s father-in-law who was healthy and worked every day of his life even though he’d been retired for thirty years and was up on a ladder pruning a tree when he started having problems catching his breath. I mean when you’re over ninety years old you might sometimes have trouble catching your breath when you’re working hard. They took him to the hospital and they put him on morphine to “ease the pain” and he was dead within 24 hours. I visited him too with the family gathered around waiting for him to take his last breath. I’ve seen it happen enough times to realize this is not right. When I was in the hospital after they amputated my leg they put me on morphine. I was drugged up and basically out of it. They kept me in bed 24/7 wouldn’t even let me get up to go to the bathroom. They had some kind of device hooked up to me where if I ever felt pain all I had to do was push a button to inject a dose of morphine directly into my IV. Good thing I finally realized what was happening and had them disconnect it. Was up a couple days later, in therapy, then got the heck out of there. Was never so glad to get home in my entire young life.

P.S. I was a caregiver for seven years, and only wish I could have seven more. But, it was not to be, no matter how much all of us who loved him hoped. We kept John Paul II as our hope for the husband and father we loved so much.

When people are obviously dying in the very last stages of advanced cancer, artificial nutrition and hydration is not necessary.

Unfortunately, the industry has used the fear of this "prolonging a painful death," and used it to promote the removal of hydration and nutrition from those also who are not dying from cancer or advanced organic brain disease like jacquej described, but simply "failure to thrive" and dementia and stroke patients.

Deliberate dehydration in these latter circumstances, despite what the palliative care industry says, is a very uncomfortable (indeed, "tortuous") process, the symptoms of which must be masked by morphone, sedatives, haldol, etc.

A friend of mine is a hospitalist in Harrisburg. He says 50% of the patients admitted to the Catholic hospital where he works with advanced dementia or severe stroke are dead within a week. He calls it "7 day euthanasia," because these patients are not terminal unless you withdraw hydration. They are placed in palliative or hospice care, their food and water is withdrawn, they are given morphine, and they are dead in 7 days.

That is euthanasia, and it is occurring on a large scale in this country and abroad.

It is going on in hospice care as well as palliative care.

Yes, there are incredible individuals and individual hospice and palliative care programs out there offering compassionate, truly ethical care. I know some of them personally. But that is not universally the case. Far from it.

My neighbor had a husband who was married before, and was estranged from his children from that first marriage. He was diagnosed with emphysema..

He did have emphysema, but as soon as my neighbor would leave for work, her ill husband somehow found the strength to leave his sick bed, and walk around the backyard drinking beer.. all day long..

He’d get drunk, and retire to his sick bed before she returned home at 4pm..He also took meds (benzos), so he’d be totally wasted by the time she got home..

She would tell me how ill he was, and how he could barely walk, and was so weak, and ill..
“His eyes are glassy. His speech is slurred. I think this could be it. He’s dying.”
I would say, “He’s not dying. He’s higher than a kite. He’s been drinking and doing drugs all day.”

Basically he was a benzo’d up drunk who was trying to reconnect with his children by feigning his soon to be dead and gone act.

He even went so far as to get Hospice involved..Apparently, the government will pay hospice for a period of time, plus one extension if you don’t croak on time.

I told my neighbor that her husband would go in the backyard every morning when she left for work, and that some of his symptoms of “croakousity” were being on beer all day with benzo’s, and then later on benzo’s and oxcontin..

On the last day of his second government funded hospice extension, She was given morphine to administer to him by eyedropper on his tongue for his pain (that he really wasn’t in)..
At first, half hours apart, then fifteen minutes apart..He received his last drops of morphine at 11:15pm, after several hours of begging her to stop the morphine, that he had been faking the severity of his emphysema to reconcile with his kids, and he didn’t want to die...

She heard that plea, but continued the morphine She said Hospice had told him to give him all the morphine, even if he asked her to stop.

She said his breathing became slower, and his respirations shallower as the hours passed..I tried to explain that morphine is a CNS depressant, so yes, it will cause you to breathe, and everything else more slowly, and finally stop breathing.

At 11:45 pm.. He died.. right on schedule.. fifteen minutes before the government funding for hospice ran out..Sometimes being a manipulative old drunk has a high cost.

It’s an interesting position. Until my experience with my father, I had not thought about the industry around dying. It is there, though, somewhat systematic and quite effective in achieving its primary goal.

I do not have experience with others and other types of disease that you have from which to draw. I can see where the same approach applied to other diseases could be exactly the wrong treatment, but again it appears to me to be such a personal decision if you are able to make it lucidly and conscientiously.

In addition, where is the family or friends in situations that you describe? Having an advocate who knows your wishes seems critical.

Hospices get stingy when they administer oxygen (and I'm not talking about ventilators). Seldom do they have the correct equipment around and even when they do they don't seem to care when the tubes fall out.

This happened to my Mom. Her oxygen concentrations were dropping into the 80's and she was becoming confused. Nobody seemed to care. I made the hospice go out and get the correct equipment resulting in an extra week of clarity for my Mom.

They'll saturate you with morphine, starve you of oxygen and send you off early.

We had my mother in law’s pain managed quite well with Fentanyl patches and oral opioids for breakthrough pain for her metastatic bone cancer. We cared for her at home around the clock 24/7 for months and she had very little pain. We had it titrated quite well, and coordinating with her oncologist and our pharmacist, we gradually increased doses of one or the other as breakthrough pain occurred. We had a visiting home hospice nurse (my mother in law’s decision, not ours) who was concerned one day when mom had some pain in her side. In hind sight, it was a met in her rib cage, but the hospice nurse wanted her checked out at the hospital. My wife had been with her 24 hours a day for weeks, and when she was admitted, they told us to go home and get some rest. They admitted her to hospice on the hospital floor for “pain management.”

They discontinued her Fentanyl patches and Vicodin and started her on the hospice pain protocol, liquid morphine, at 5mg every two hours. That didn’t touch her pain. When we stopped in the next day, she was writhing in agony, saying, “Lord, please take me now. Lord, Please take me now.” We were beside ourselves, we had managed her pain for months with very little major discomfort. We asked the nurses what the hell was going on, and they said, “Well, she has to request the pain medication, and she hasn’t requested any.”

She didn’t know she had to request it, she didn’t know where her nurse call button was, and she couldn’t reach it due to the pain if she had!

So we had to stay there at the hospital and go request it every 2 hours for the next two days. And 5mg of liquid oral morphine is NOTHING for someone who had been on Fentanyl patches and oral Vicidin for breakthrough pain for over a year.

She deteriorated rapidly and we had to BEG them to increase the morphine dose. They started her on long acting morphine pills (MS Contin) and we finally got her back home and spent days fighting with the hospice and their pharmacy contract company to get her back on the Fentanyl and Vicidin.

We were talking to a pro-life Catholic hospice during this for advice, and they wanted to know what the local hospice was planning for pain control once mom could no longer swallow, a point which was rapidly approaching. The local hospice said they’d simply give her the MS Contin pill as a suppository. You don’t roll over a woman with a history of spinal metastasizes and vertebral pathological fractures to give them a suppository for pain control several times a day!

She was becoming incoherent, repetitive, could no longer carry on a conversation, and was rapidly dehydrating.

So I finally blew up and coerced them (I won’t go into details, but it wasn’t pretty) into putting her back on the Fentanyl, and starting an IV for hydration. (It took them 5 days to get the IV order filled!)

As soon as she was rehydrated and the morphine was washed out of her system with the IV hydration, and the Fentanyl patches took effect, she was able to talk and carry on a normal conversation once again, and had better pain control without agitation or confusion compared to the morphine.

Our experience with hospice was not the wonderful experience others desribe. It was a harrowing experience in which we had to fight 24 hours a day for proper care. And I don’t have the energy to relate the battles we had to fight for proper care for my father in law, who passed away at home under hospice care (again, my mother in law’s decision, not ours) two years ago.

And why did they insist on the morphine instead of the Fentanyl? We’re still not sure, but Morphine costs pennies and makes the patient quiescent, which makes for less demands for active care and assistance. Fentanyl is expensive and the patient can maintain their activity level.

So that’s some of my direct experience of palliative care (in Fr. Gerard’s case) and hospice care (in my mother in law’s case) so my opinions on this subject are not based on hearsay.

And I’m in routine contact with the Hospice Patients Alliance, which fields calls and takes emails on cases like these every day. The stories are harrowing, and incredibly sad.

There are still some really good hospices and palliative care services, and even in ones that are questionable, there are truly angels or mercy doing their best in a terribly imperfect system.

Dude, you claim to be a doctor and for now I’ll give you the benefit of the doubt. In my time on FR there have been dozens claiming to be this and that. Maybe you are and maybe you aren’t.

If you are a physician you had a huge advantage dealing with your profession that most here will never have. You need to realize that. If the average Freeper started arguing over medications and dosages with “professionals” they’d be ignored at best or be accused of aiding an addiction at worst.

71
posted on 04/29/2012 9:54:47 PM PDT
by Lurker
(The avalanche has begun. The pebbles no longer have a vote.)

** aggressive pain and symptom management (even to the point of unconsciousness), along with a greater willingness to withdraw advanced, life-sustaining treatments such as mechanical ventilation, dialysis, and artificial hydration and nutrition  still strike many people as wrong.**

It is wrong. I have often wondered after my husband died if the morphine had anything to do with hastening his death. He was unconscious, but could still hear us and reached out to give me and all five children a hug.

I’m just a Podiatrist. That doesn’t carry much weight in this scenario.

But morphine is not the drug of choice in metastatic bone cancer pain. The Catholic hospice gave me the resources to make the argument (I didn’t know that, not much chronic pain management in my specialty) and get them to put her back on it.

A wonderful weekend experience for those who have suffered the loss of a loved one.

The website has locations — there may be one in your area. It is patterned after the Marriage Encounter weekend with peers who have lost loved ones giving talks, then a reflection time, then a small group time, rather than couple time (ME weekend)

Kevin O'Reilly has written an article, "End-of-life care: Pain control carries risk of being called a killer - Accusations of euthanasia are common as patients, families and even other health professionals struggle to adjust to the new realities of end-of-life care." Mr. O'Reilly is a writer for the American Medical News, a publication of the American Medical Association. This is my response:

As a patient advocate and President of the Hospice Patients Alliance, I've spoken with many hospice and palliative care leaders, physicians, staff as well as families and patients from all across the United States. It is truly disingenuous and misleading to state that "all of these treatments" "... are "broadly accepted as ethically and legally appropriate, "even if they have the secondary effect of speeding the dying process." What is occurring in hospice and palliative care settings is not a "secondary effect" but an intended primary goal today.

Anyone involved in end-of-life ("EOL") care knows that the praiseworthy and lofty goals of the hospice and palliative care mission asserted for decades that the services provided would "never hasten death." Today, the removal of nutrition and hydration, whether artificial or not, often combined with the permanent sedation of the patient ("terminal/palliative/total sedation") is being done in EOL settings, with the intent that the patient die.

This is confirmed by hospice physicians serving as medical directors, nursing directors, nurses, social workers, chaplains and other physicians all across the country. As mentioned in the article, many oncologists are often shocked that their patients suffering from a terminal illness, but in no way in the technical "active phase of dying" and therefore not expected to die suddenly, actually die within days or weeks of entering hospice and palliative care settings. All of these professionals can not all be wrong or ignorant. They know what is really happening.

It is relevant to note that one of the foremost authorities in modern palliative care, Joanne Lynn, MD confirms this and was quoted in a NY Times article, "'Passive Euthanasia' in Hospitals Is the Norm, Doctors Say" and said "when a patient is ready to die, I can stop nutrition and hydration, I can stop insulin and ventilation, I can sedate them." This is intended death, not death from a terminal illness! If such a leading authority on palliative care as Dr. Lynn admits that passive euthanasia of this sort is the "norm" in hospitals and health care, then the author's statements about "misunderstandings" and "misperceptions" are in error. The reality is that intended death is occurring.

In addition, Timothy E. Quill, MD and Ira R. Byock, MD (a leading hospice & palliative care physician), and the ACP-ASIM End-of-Life Care Consensus Panel suggest that when patients request "that death be hastened," terminal sedation and voluntary refusal of hydration and nutrition" be used "as potential last resorts that can be used" to hasten their death. [See: "Responding to Intractable Terminal Suffering: The Role of Terminal Sedation and Voluntary Refusal of Food and Fluids," by Timothy E. Quill, MD; Ira R. Byock, MD; and for the ACP-ASIM End-of-Life Care Consensus Panel. Annals of Internal Medicine, March 7, 2000 vol. 132 no. 5 408-414] Again, this is intended death, not from a terminal illness, but the actions of the physicians, and they do not require the nutrition and hydration to be "artificial" when such intended death is imposed.

Therefore, in addition to directly causing euthanasia by a lethal agent, contrary to AMA policy, hospice & palliative care physicians are urging and actually performing such euthanasia by stealth, using a method that is not direct euthanasia, but intends death, causes death and is done using sedative medications that in themselves do not cause immediate death, but cause the conditions that knowingly result in death.

In other words, the misuse of terminal sedation to end life is another form of euthanasia, properly termed "stealth euthanasia," which I have written extensively about in Stealth Euthanasia: Health Care Tyranny in America. It is not direct euthanasia as a lethal agent is not used to immediately cause death, and it is not true "passive euthanasia" because it is not simply withholding or withdrawing treatments.

The misuse of terminal sedation to cause death creates the situation where the patient cannot take in nutrition or hydration, whether artificial or natural, because he is in a medically-induced coma, and certain circulatory collapse occurs from fluid volume deficit in a few days to a couple of weeks, depending upon the patient's condition.

It may be "justified" using several bioethical arguments that devalue the value of the patient's life and assert that the patient would be "better off dead" than suffering from their terminal illness, debility, dementia, disability, etc. It is also justified by the principle of "patient autonomy," yet many of these patients are not requesting such imposed death through any means. In hospice today, there are very real concerns that the mission is being twisted into something other than what most people expect, i.e., end-of-life care, not imposed death.

It is no accident that families, staff, hospice and palliative care professionals are themselves warning that euthanasia, direct or passive, and stealth euthanasia are being performed in the EOL setting. The National Hospice & Palliative Care Organization is the actual legal and corporate successor to the former Euthanasia Society of America, and continues the twisting of the life-affirming mission of hospice and palliative care into something other than what it represents itself to be.

Using the doctrine of the Law of Double-Effect, the author, and those like him, assert that practices such as sedating a patient permanently, while also removing artificial as well as natural nutrition and hydration, thereby assuring death, are justified under the guise of their being a "secondary effect," when actually it is the primary effect intended; these practices are therefore forbidden by the Law of Double Effect, since the primary intent, i.e., to end life, is unethical.

Whether these practices that knowingly result in imposed death are justified by principles such as patient autonomy, beneficence or justice, or the misuse of the Law of Double-Effect, such justification is exposed as unethical when the AMA's own statement on euthanasia is considered, that "the societal risks of involving physicians in medical interventions to cause patients' deaths is too great to condone euthanasia or physician-assisted suicide at this time." In other words, the AMA already condemns the practice of physicians intending and causing death.

The ambiguity created by "stealth euthanasia's" methods avoids the readily identifiable terms "euthanasia" and "assisted-suicide," but results in imposed death just the same and is condemned by the AMA's own ethical stance against intended death.

MANAGEMENT: During concomitant use of these drugs, patients should be monitored for potentially excessive or prolonged CNS and respiratory depression. Ambulatory patients should be counseled to avoid hazardous activities requiring mental alertness and motor coordination until they know how these agents affect them, and to notify their physician if they experience excessive or prolonged CNS effects that interfere with their normal activities.

If you are a physician you had a huge advantage dealing with your profession that most here will never have. You need to realize that. If the average Freeper started arguing over medications and dosages with professionals theyd be ignored at best or be accused of aiding an addiction at worst.

In my 27 years as caregiver I took on about seven doctors at once over medication. This had nothing to do with Hospice or terminal illness but rather a disabled person. She had PTSD from some bad things like instant quadriplegia, a misdiagnosed non heart ailment she took meds for 15 years needlessly and other things. But the real kicker came when she needed something to help her face some extensive oral surgery. A dentist a few years before had pulled her tooth and gave her Mepraghan. She went into a Coma and a temp of about 89-90 degrees. A patient later died in his dental chair from an unathorized anthieasa he was not qualified to do.

So she goes to a shrink and he gives her two antidepressants Trazadone and Zoloft. Oh the first couple of months she improved then she became highly agitated in a matter of a day. I rush her to the shrink and he says well lets up the meds see you in three months. By the time we get home she is hallucinating. We went to the ER. Because she could not think clearly enough to sign for treatment I was not allowed to sign for her either. I am her husband.

I go and make some calls to family because the doctor said he was not going to do any blood work, EKG, CAT Scan OR MRI despite her spinal stroke history. I go back in the ER and I finally find her in her wheel chair passed out unresponsive shaded closed on her room. I yelled Help Stat and the doctor came in and just stood there. I said she's unconscious do something and he said no. I said you stupid {word I will not post} psychosis or mental illness does not do this.

I loaded her up in the van and went to a level one hospital. They were very eager to help her. They got her conscious again then it started all over again. She is psychotic and we can not treat her we are calling the state. I waited and Mobile Crisis arrived. I proceeded to inform them in no uncertain terms this hospital was going to do something including testing. They agreed.

They took her of all meds but Ativan. Within about 36 hours she was pretty much herself again. Now you would think that would tell them something. Still no MRI. In walks Joe Shrink who never saw her before and says lets go ahead and up the meds {antidepressants}. In an hour the pills were brought in. Within another hour it all started all over. I am not a doctor but that is a bunch of red flags. She was out of it thrashing and talking about events I knew about. It was as if she was replaying her life.

I'm a Christian and I believe 100% in the power of prayer. Day Four I went to the Chapel in the hospital before going home for some sleep. My dad came in to relieve me. I got home and for some reason went on line and typed in Trazadone +Zoloft +Adverse reaction. Instant hits and the right ones. I read two articles and I was certain she had Serotonin Syndrome. I called my dad and said I know what's wrong with her and I'm on my way back right now don't let them give her any meds till I get there.

I went to the nurses station and requested to speak to the floor supervisor. I showed her the articles and they were highly credible sources. I said call the doctor {who wasn't our primary but a hospital contractor} and tell him. She said No we don't do that he comes in in the morning. I said OK then these are my orders. You will only give her the Ativan prescribed her. You do not have permission to give her any other medications.

Next morning the doctor came in madder than a hornet getting me out in the hall and said why did you stop her antidepressants? I said please just read this. He glanced at it and said that is pure rubbish. I said and the Pharmacology Professor who wrote is works where? It was a university hospital same university. He said oh well maybe it is then now lets see about getting her a transfer to mental facility. I looked at him ans said you mention that one more time and you will regret ever saying it. You were wrong. No one did a Physicians Desk Reference. His behavior became subdued and next morning she was back to being coherent but had partial amnesia some of which she still has. Next morning they came to get her for a MRI. Two bleeders in her brain one old and one fresh.

I've taken on Medicaid in my state as well. You just have to keep fighting and not back down. Hard to do sometimes. If my wife had not also been taking Xanax she likely would have died from this. Benzo's are the counteracting drug too Serotonin Syndrome. But I've learned what I know from help from nurses I used to work with and a computer if you use legit sources can be invaluable as well.

82
posted on 04/29/2012 10:35:33 PM PDT
by cva66snipe
(Two Choices left for U.S. One Nation Under GOD or One Nation Under Judgment? Which one say ye?)

“If the average Freeper started arguing over medications and dosages with professionals theyd be ignored at best or be accused of aiding an addiction at worst.”

No, Lurker, I’ve done it many times. I speak with a professional voice and tell them what has worked and hasn’t worked and I didn’t give up until they did it right.

I have also worn a white shirt and put my pin with my name on it with the word “Dr.” before my name (Ph.D. kind not medical doctor kind, but they didn’t ask), and the nurses did anything I said. They are conditioned to white and Dr. and jumped in hoops if I said do it.

I used every psychological ruse I had, to get done what needed to be done. Those employees are just employees and you are paying them, so tell them what to do. Don’t let them intimidate you, you intimidate them.

One time he was in a hospital room, ready to go home but the nurses wouldn’t do the paper work at their station. You are leaving and they are through with you so they don’t care if you stay in the room waiting forever. I rolled him out to in front of their station and had him ask for food, coke, etc. and I stood there and stared at them. They couldn’t stand it so got right on the paperwork and we were out of there really fast.

Don’t disappear, stay close to the nurses’s station staring at them and you will get what you need.

I have years of experience with hospital employees and doctors and I’m going to win and they are going to lose.

83
posted on 04/29/2012 10:36:23 PM PDT
by Marcella
(Romney: for Abortion, homosexuality, same sex marriage - No to Romney)

“The ambiguity created by “stealth euthanasia’s” methods avoids the readily identifiable terms “euthanasia” and “assisted-suicide,” but results in imposed death just the same and is condemned by the AMA’s own ethical stance against intended death.”

This is exactly what I found when I investigated that hospice place. They were going to fill him with morphine and withhold water/food. I went through that place and looked at everything there. There was nothing to save a life. As a licensed EMT, I saw it for myself and knew what to look for to save a life and nothing was there. I stand by the name I gave them - “Death House”.

84
posted on 04/29/2012 10:47:23 PM PDT
by Marcella
(Romney: for Abortion, homosexuality, same sex marriage - No to Romney)

Thank you for your reply. The “concomitant use of these drugs” was short term. From early August 28, 2011 to 1:20 pm August 29, 2011, an otherwise beautiful, warm summer afternoon. No longer any need for the recommended counseling.

But I do miss her terribly. Her photo sits on the desk in front of me, and to the left. It is one of those photos where the eyes follow you, no matter where you view it from. Even this photo projects her love and humanity.

I do miss her so.

85
posted on 04/29/2012 10:51:01 PM PDT
by RobinOfKingston
(The instinct toward liberalism is located in the part of the brain called the rectal lobe.)

Marcella, what you say is true - a hospice is a place for terminally ill patients to go to prepare for death. That is what they are. They are not treatment centers. If anyone claims they are, they are lying.

Some people choose them over suffering - others find it beyond consideration for themselves or thier loved ones.

I’m glad you found an option that was good for you and your husband.

86
posted on 04/30/2012 2:47:07 AM PDT
by An.American.Expatriate
(Here's my strategy on the War against Terrorism: We win, they lose. - with apologies to R.R.)

It seems medical technology has advanced to the point where difficult end-of-life decisions must be made. People didn’t have a lot of options in the past. Now they can keep people alive well beyond where they once would have died.

Personally? I don’t think hydration or nutrition should ever be withheld from a patient (who can take them) in order to hasten death. On the other hand, I witnessed a loved one die a very long, excruciating death from cancer. There was point where the person no longer existed, and the only apparent options left were horrible, unremitting pain or drug-induced unconsciousness.

There’s a point where death is a blessing. I don’t want a doctor hastening my death, but I also don’t want one trying to keep me alive only to suffer mind-destroying levels of pain when I’m beyond hope. Unless someone has had a loved one go through a death like that, they have no business criticizing someone who has.

I understand the whole concept, but after spending time there with a relative and noticing more than a dozen deaths in a week, I felt like I was in a death mill. Some people who were up the day before, were gone the next. A father was saying about his teen daughter, she had six months, but died 10 days after going to hospice..he was in shock. Well, the whole thing freaked me out.

How I wish more families would keep their loved ones at home for their final days. But some just aren’t up to it.

Hospice should offer the option of home care. The ones I’m familiar with do.
However, there’s no reason to make these accusations, anymore than to say that all of the people on ventilators can’t breathe!

The definition of hospice care is that death is expected with in 6 months due to a serious illness.

Hospice in patient facilities are used for the last few days - they don’t cause death. The people who are admitted are only those in the last stages of an illness that’s killing them.

And yes, I’ve had patients “kicked off hospice Medicare because the excellent care the hospice nurses gave my patients better health. Two that I remember died in the hospital within a month of losing hospice nurse care. (And before we could fight the Medicare bureaucracy. ) One had unstable angina, severe pain and shortness of breath that her family couldn’t bear. Another lived alone, had no family, and had extreme COPD with frequent attacks. The hospice nurses made home visits, attended to their needs when they got worse.

The truth about hospice care is that it is in most cases, compassionate care, compassionate to the patient and to their families. I knew two people, the nieces of my husband who both received in home hospice end of life care. One died in her late 20s from acute leukemia within six months of her diagnosis. The other battled breast cancer for several years before it metastasized and went into her lungs and brain.

They were cared at home by dedicated around the clock hospice nurses. They were able to meet their inevitable end in the warm, comfortable and familiar surroundings of their home surrounded by family and friends and children who could be with them 24-7 in a non hospital setting.

In both their cases, the cancer treatment, chemo, radiation, etc. had stopped as they were fruitless and only palliative care, nutrition, fluids and pain medication like morphine was given. But in their final days and hours the pain would have been excruciating without the morphine.

The thing that some people dont understand is that in the final days and hours before death, as internal organs start shutting down, fluids accumulate around the heart and in the lungs, making breathing a struggle and an excruciating one at that. What morphine does is to not only relieve the pain but it also depresses respiration, relaxes the patient and opens up their air ways. The fluid still builds up still ultimate kills them but the morphine makes the process less horrific  no desperately gasping and struggling, realizing they are drowning in the their own fluids and contorting their bodies or even having seizures or strokes as they gasp for their final breaths.

If a person is in their very last days or hours of life and administering morphine eases their pain, even if it by its properties, it hastens death by only a few hours, I do not consider that euthanasia.

I understand the whole concept, but after spending time there with a relative and noticing more than a dozen deaths in a week, I felt like I was in a death mill. Some people who were up the day before, were gone the next. A father was saying about his teen daughter, she had six months, but died 10 days after going to hospice..he was in shock. Well, the whole thing freaked me out.

As hospice care is for the terminally ill, Im not sure why you were so shocked that there were deaths. As far as some people who were up the day before, were gone the next sometimes thats how death works and that part of the process is not fully understood but is often observed. Its not all that unusual for a terminally ill person to experience a rebound and appear to get better and then very suddenly take a turn for the worse and die very suddenly.

As far as the dad who thought is daughter had six months; sometimes doctors, being themselves human, will not always be 100% truthful about a patients prospects. Right or wrong, sometimes doctors have a difficult time dealing with death themselves and will give patients and their families the most optimistic prognosis either because they themselves dont want to give up hope or think that being 100% honest would be counter-productive. It is also possible that the initial prognosis of six months was reasonable but that the child suffered an unforeseen complication.

May your dear Husband rest in peace—the undying loyalty of such a mate for life is truly inspiring.

I just watched my Mother-in-law die under hospice care a couple of months ago. It did make me feel uncomfortable to see her drugged up to the point where she couldn’t communicate with her family. Of course, being drugged up is the name of control of more than half of the patients in a nursing home. I honestly think my Mother-in-law was thoroughly addicted to pain medications—fentanyl, then other opiates. Yes, they die in a stuperous, pain-free state, but is it right?

96
posted on 04/30/2012 7:23:56 AM PDT
by Neoliberalnot
(Marxism works well only with the uneducated and the unarmed.)

Mariner specifically wrote about the comment that one patients died of overdoses, when the article is about attempts to control pain.

Brian is the instigator, here. He posted this, pinged his buddies, and then called you for help when he got the response he expected. The original post wasn’t aimed at you, only a rude accusation by Kopp.

There are real murderers out there, but this discussion and the original post are not about them. Kopp wants this to be about the care that includes pain control, too.

I am one of those doctors - an MD with an ethics degree, - who is accused of euthanasia because of pain control and other judicious, medically and ethically thought out care. I’m also pilloried by the utilitarian “bioethics” who assume intentional and even involuntary killing should be in the doctor’s job description.

The fear of pain is the usual reason for advocates of intentional euthanasia. The accusation that pain control necessarily involves killing the patient is flat out wrong and Brian knows it. I’ll bet that as a podiatrist, he’s used pain killers, even opiates.

Brian is the instigator, here. He posted this, pinged his buddies, and then called you for help when he got the response he expected. The original post wasnt aimed at you, only a rude accusation by Kopp.

********************************

What a scurrilous charge.

98
posted on 04/30/2012 7:41:15 AM PDT
by trisham
(Zen is not easy. It takes effort to attain nothingness. And then what do you have? Bupkis.)

I just watched my Mother-in-law die under hospice care a couple of months ago. It did make me feel uncomfortable to see her drugged up to the point where she couldnt communicate with her family. Of course, being drugged up is the name of control of more than half of the patients in a nursing home. I honestly think my Mother-in-law was thoroughly addicted to pain medicationsfentanyl, then other opiates. Yes, they die in a stuperous, pain-free state, but is it right?

First of all, let me say that Im sorry for you and your familys loss. It is never easy under any circumstances. Ive been there with my MIL and both my parents and other family members.

But then let me ask you a few honest questions. If your MIL was in excruciating and constant pain, would she have been at any point of having meaningfully communication with you? And was she in a nursing home or a hospice care facility? They are two very different things. I do not BTW have a very good opinion of most nursing homes from what Ive observed. My experiences with those Ive know in Catholic hospice care, both in a facility and with in home care, is vastly different than what I observed in commercial nursing homes.

As far as being addicted to pain meds, if a person is in their final days and hours of life, what difference does that really make if they are addicted? Its not as if a dying person in their very last days or hours of their life is going to suddenly get up out of their bed and hold up a pharmacy looking for drugs or hold you up at the ATM looking for cash to support their drug habit. The sad thing is that many people in chronic and debilitating pain are now being denied medication out of fear of addiction. While some people who are addicts and not in need of pain relief, their abuse of the system means that many who are in need of such meds are treated like addicts whether they are or arent.

Yes, they die in a stuperous, pain-free state, but is it right?

So what is the alternative? Withhold all pain meds from the terminally ill and dying? Would you really want that for someone you care about?

“Brian is the instigator, here. He posted this, pinged his buddies, and then called you for help when he got the response he expected. The original post wasnt aimed at you, only a rude accusation by Kopp.”

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